Inspection on 18/08/06 for The Orchard

This inspection was carried out on 18th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Orchard 12/03/09

The Orchard 29/07/08

The Orchard 28/09/07

The Orchard 06/12/05

The Orchard 15/11/04

The Orchard 14/06/04

The Orchard 20/08/03

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Orchard High Street South Stewkley Bucks LU7 0HR Lead Inspector Chris Schwarz Unannounced Inspection 08:00 18 August 2006 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000023068.V289406.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000023068.V289406.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Orchard Address High Street South Stewkley Bucks LU7 0HR Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01525 240240 01525 240464 orchardstewkley@supanet.com Mrs Pauline Hannelly Mrs Pauline Hannelly Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places DS0000023068.V289406.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th December 2005 Brief Description of the Service: The Orchards is a care home registered to provide personal care for 11 elderly people. It is a large detached house with well-maintained gardens. It is situated in the rural village of Stewkley and is close to local amenities. The home is privately owned and managed and is the private residence of the Proprietor/Manager. All of the rooms are single rooms with en suite facilities. Residents have their own sitting/dining room and there are attractive accessible gardens. All service users are registered with a local GP Practice and have access to local NHS Services. Fees for the home are £550 per week. Information supplied by the provider with pre-inspection material. DS0000023068.V289406.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted over the course of a day and covered all of the key standards for older people. Prior to the visit, a questionnaire was sent to the provider/manager alongside comment cards for distribution to service users, relatives and visiting professionals. Any replies received from the comment cards were taken into consideration during the inspection and have helped to form judgements about quality of care. The inspection consisted of discussion with the provider/manager and opportunities to speak with other members of the staff team. There were opportunities to observe care practice and to meet with service users to gain their views. A tour of the premises and examination of some of the required records was also undertaken. At the end of the inspection, feedback was given to the provider/manager. Staff, service users and the owners are thanked for their co-operation and hospitality during this visit. What the service does well: Health care is generally well managed at the home, ensuring that service users receive the assistance from health care professionals that they require. Service users are afforded the privacy and dignity they require, to maintain well being and self esteem. The home meets the expectations of service users and offers opportunities to express faith and engage in activities. Contact is maintained with family and friends, ensuring that important social relationships continue. Service users are enabled to exercise choice and control in their lives, with support if required, to retain independence. The diet is wholesome and well presented, ensuring that service users’ nutritional needs are met. Complaints procedures are in place to listen to the views of service users and their representatives. Pleasant, comfortable and clean surroundings have been created for service users, providing them with a homely and well maintained environment. DS0000023068.V289406.R01.S.doc Version 5.1 Page 6 Sufficient staff are deployed to work at the home in order that needs can be met. Service users are protected by the home’s recruitment procedures, ensuring that only thoroughly vetted people work at the home. Induction and on-going training for staff are well managed, ensuring that staff have the necessary skills and knowledge for the job. The home is appropriately managed by an experienced and qualified person, to ensure that there is consistency of care. Most areas of health and safety were being effectively handled, to reduce the risk of accidental injury. What has improved since the last inspection? What they could do better: Pre-admission information is not sufficient to ensure that needs are thoroughly assessed, recorded and entered onto a plan of care. This could mean that service users’ needs are not fully met as a consequence. Service user plans are not in sufficient detail to ensure that care needs are fully met. DS0000023068.V289406.R01.S.doc Version 5.1 Page 7 Policies and procedures relating to health issues need revision, to ensure that best practice is followed. Medication practice needs some attention to ensure that safe practice is followed. The element of risk associated with the public using the owner’s swimming pool, in close proximity to service users, needs to be evaluated. Adult protection procedures need revision, to ensure that incidents are appropriately handled and reported to the relevant authorities. These should be backed up by refresher/first time training for staff. Quality assurance needs to be developed within the home, to ensure that service users receive the care they require. The water supply needs testing for Legionella species, to ensure that there is no risk to service users. Risk assessments are needed on the use of supplementary electric heaters, to ensure that the likelihood of accidental injury is minimised. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000023068.V289406.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000023068.V289406.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Pre-admission information is not sufficient to ensure that needs are thoroughly assessed, recorded and entered onto a plan of care. This could mean that service users’ needs are not fully met as a consequence. EVIDENCE: The files of three permanent service users and one occasional service user were looked at. In respect of a service user who stays at the home on an occasional basis, there was limited information and no assessment of needs. For the three permanent service users, some information was available but this was in forms such as information supplied by a relative or what was recorded on the care plan, with no distinctive pre-admission assessment evident to cover all of the care needs as outlined in the standard. A clear pre-admission assessment tool needs to be used by the home to ensure that service users’ needs are thoroughly evaluated before a place is offered to them. DS0000023068.V289406.R01.S.doc Version 5.1 Page 10 Copies of contracts were available. These need to be amended to reflect that the Commission for Social Care Inspection is the regulatory body for care homes, not the National Care Standards Commission. Similarly the information given to service users about complaints should be amended to reflect that the local authority is not the regulatory body. DS0000023068.V289406.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service user plans are not in sufficient detail to ensure that care needs are fully met. Health care is generally well managed at the home, ensuring that service users receive the assistance from health care professionals that they require. Policies and procedures relating to health issues need revision, to ensure that best practice is followed. Medication practice needs some attention to ensure that safe practice is followed. Service users are afforded the privacy and dignity they require, to maintain well being and self esteem. DS0000023068.V289406.R01.S.doc Version 5.1 Page 12 EVIDENCE: Care plans were in place for service users, apart from a person who occasionally stays at the home. A care plan needs to be written for this service user, with accompanying risk assessments put in place. The care plan format used at the home could be a useful tool if fully completed, dated and signed. One person’s mental health needs stated that she had depression but the care plan did not show that an anti-depressive medication is prescribed and any arrangements for monitoring by community psychiatric services. The section on food and drink for a service user did not refer to the presence of irritable bowel syndrome and any foods that should be avoided or which aggravate the condition. Sections on daily living, leisure, personal values and dying were not consistently completed, omitting potentially important information about service users’ needs and aspirations. Dates and signatures were not being consistently added therefore it was not always possible to see how old the information was. Risk assessments need attention at the home. A basic evaluation list is in place which would be useful if supplemented by full assessments of each risk on the list. There were no risk assessments for managing pressure areas in the sample of files examined despite one of the service users in the sample being referred to the district nurse and the provision of pressure relieving items. Assessment of moving and handling is too basic, with no additional details where “staff help required” is indicated. The website for the Health and Safety Executive may be useful to the provider/manager in developing this area of practice. Health care needs seemed to be well managed, with good service from the doctors’ surgery and prompt attention on the day of the inspection following a request by staff to visit a service user. File notes showed that there is input from various health care professionals, such as doctors, district nurses, a chiropodist and a physiotherapist. There was evidence of seeing the optician and assessment for incontinence products by the district nurse. Records of weights were being maintained. The policies and procedures to guide staff on health related matters were largely written in 2002, 2003 and 2004 with no evidence of being reviewed. These should be reviewed every year to ensure that staff have up-to-date information on best practice in care provision. Medication was kept secure and the cabinet locked when not in use. There were no gaps to medication administration records and the person administering medication in the morning had appropriate training. There were just a couple of points raised with the provider/manager. A protocol needs to be in place for any medication prescribed “as required”, in this case lorazepam. DS0000023068.V289406.R01.S.doc Version 5.1 Page 13 A protocol should have been written as soon as the medication was received into the home. Notes showed that staff have been giving an occasional service user her prescribed eye cream and a tablet was in the cabinet to give out to her later in the day. No medication administration record had been set up to record the details; a requirement is made to address this. Service users looked well groomed and were appropriately dressed for the weather conditions; blankets were offered to them when it turned colder. A manicurist and a hairdresser visit the home and both have done good jobs in maintaining appearance and promoting self esteem. Service users who wished to be in their rooms were enabled to do so and all doors were knocked on before entering during an accompanied tour of the premises. DS0000023068.V289406.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home meets the expectations of service users and offers opportunities to express faith and engage in activities. Contact is maintained with family and friends, ensuring that important social relationships continue. Service users are enabled to exercise choice and control in their lives, with support if required, to retain independence. The diet is wholesome and well presented, ensuring that service users’ nutritional needs are met. EVIDENCE: The home is centrally located within Stewkley on the main street and near to the chapel. Some of the service users make use of the Bright Hour run by the chapel which involves different talks and tea and biscuits afterwards. A priest visits the home to give communion to one of the service users and the provider/manager is intending to extend links with the local vicar. A hairdresser and manicurist visit. DS0000023068.V289406.R01.S.doc Version 5.1 Page 15 The home runs a Friday programme and fortunately this visit coincided with opportunity to observe it in action. The activity organiser devises a different theme each week on topics which service users may find stimulating, often resulting in reminiscence about times gone by. Some of the service users have televisions and audio equipment in their rooms and prefer to do their own thing. Newspapers are ordered for any service user who would like one. Relatives responding on comment cards said that they are made to feel welcome when they visit and can see service users in private if they wish. There is further contact with the community on days when the provider/manager’s swimming pool is open to the public and service users often sit outside and watch. Most of the people coming to use the pool would be known to the provider/manager but there could be strangers who would be in close proximity to service users. A risk assessment needs to be prepared to ensure that service users’ well being and safety are not compromised by this arrangement. Service users had brought in personal possessions for their rooms and each room was arranged to different tastes. No one was handling their own financial affairs or medication. Meals are well presented and service users said that they enjoy the food and have plenty to eat. The dining table was very nicely decorated and conducive to a pleasant social gathering. DS0000023068.V289406.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Complaints procedures are in place to listen to the views of service users and their representatives. Adult protection procedures need revision, to ensure that incidents are appropriately handled and reported to the relevant authorities. These should be backed up by refresher/first time training for staff. EVIDENCE: The home has a complaints procedure and, as mentioned in the first section, this needs to be amended to reflect that the Commission for Social Care Inspection is the regulatory body for care homes. The complaints log could not be located; the provider/manager said that there had not been any recent complaints and the Commission has not received any either. People responding on comment cards said that they were aware of how to raise complaints although none of them had needed to. The home has Protection of Vulnerable Adults and whistle blowing policies. The Protection of Vulnerable Adults policy is in need of prompt update as the information is misleading and could give rise to an employee at the home investigating a matter which either the police or social services need to handle. It also needs to reflect that any allegations, suspicions or actual incidents are to be reported to the Commission within 24 hours of occurrence and needs to be in line with the local authority’s procedures, a copy of which should be in DS0000023068.V289406.R01.S.doc Version 5.1 Page 17 the home. Update or first time adult protection training for all staff should be undertaken within the coming year, to ensure that staff have the necessary skills and knowledge in this important are of practice. The Commission is not aware of any adult protection concerns regarding this home. DS0000023068.V289406.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Pleasant, comfortable and clean surroundings have been created for service users, providing them with a homely and well maintained environment. EVIDENCE: The home is centrally located within the village and is not distinguishable as a care home, except for the sign alerting of its presence. The building is well maintained and has been pleasantly decorated to present a bright and airy environment with well kept grounds. All of the bedrooms are single and have been decorated and arranged to different tastes. Each room has an en-suite shower and toilet and adaptations such as grab rails, raised toilet seats and a bath hoist are in place. It was noticed that some of the cantilever tables used by service users to rest their drinks and sundries on in the lounge were missing the edging strip, revealing a porous surface which could harbour bacteria. These tables should be replaced. A leak on the ceiling outside the DS0000023068.V289406.R01.S.doc Version 5.1 Page 19 kitchen had been caused by poor drainage in the shower above; this is being looked into by the owner. DS0000023068.V289406.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Sufficient staff are deployed to work at the home in order that needs can be met. Service users are protected by the home’s recruitment procedures, ensuring that only thoroughly vetted people work at the home. Induction and on-going training for staff are well managed, ensuring that staff have the necessary skills and knowledge for the job. EVIDENCE: Required staffing levels were being adhered to at the time of this visit with sufficient carers and domestic staff available plus the owners. Rotas reflected times of being on duty and had improved from the previous inspection. Three new staff had commenced working at the home from within the European Union. All required recruitment checks were in place, with Home Office approval to work. Their induction followed the Skills for Care model and covered a comprehensive range of care issues. All three of the new starters were introduced to the inspector and their command of English was good. Training records for these staff showed that they had attended manual handling and first aid courses and completed the fire safety training on the DS0000023068.V289406.R01.S.doc Version 5.1 Page 21 afternoon of this visit. These courses had been undertaken within about six weeks of starting. None of the new starters were involved with medication administration and would not be permitted to by the provider/manager until trained. A Criminal Records Bureau certificate for a part time member of staff had been obtained – this had been an issue at the previous inspection. Team meetings for staff were not recorded; these need to be minuted to show that they take place and the matters raised for discussion. A recommendation is made to attend to this. DS0000023068.V289406.R01.S.doc Version 5.1 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home is appropriately managed by an experienced and qualified person, to ensure that there is consistency of care. Quality assurance is being developed within the home, to ensure that service users receive the care they require. There is due regard for health and safety overall, with a couple of matters needing attention to ensure that staff, service users and visitors are adequately protected against the risk of accidental harm. EVIDENCE: The provider/manager is registered with the Commission and has attained National Vocational Qualification level 4. One relative expressed that “The DS0000023068.V289406.R01.S.doc Version 5.1 Page 23 Orchard is very well run and homely. Staff are very understanding and polite. I have noticed that all emergency exits are kept clear”. Training on undertaking quality audits has been attended by the provider/manager and some other staff connected with The Orchard and the sister home The Lindens. Quality assurance surveys were seen in service users’ files and the aim is to set up a quality assurance file with audits of areas such as recruitment practices, medication practice, health and safety and care plans. The requirement made at the last inspection for an internal audit to be undertaken has not been achieved, but measures are in place to work towards this and the timescale is extended. The home does not currently handle any service users’ finances. The fire log showed that most of the required safety checks are being undertaken regularly, apart from practice drills. Staff do not record these therefore there is no indication that they have taken place at least six monthly. A requirement is made to address this. Training on fire safety was taking place during the afternoon by a former County fire fighter and discussion with him afterwards showed that staff are given safe and good instruction. A fire based risk assessment had been completed since the last inspection and generic risk assessments were also in place. Accidents are being recorded and portable electrical appliances have been tested since the last inspection. A contract with British Gas ensures that the boilers are serviced and deemed to be working satisfactorily. A requirement to have the water tested for Legionella species had not been attend to and is repeated. The only visible hazard on the premises was the use of supplementary electric heaters in bedrooms and in the lounge. Risk assessments need to be undertaken to ensure that the risk of harm to service users is minimised, especially if they were to fall against them. DS0000023068.V289406.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 1 x x N/a HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x N/a x x 2 DS0000023068.V289406.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP3 OP3 Regulation 14 22 10(1) Timescale for action A full assessment of care needs 01/10/06 is to be undertaken prior to admission of any service user. Information given to new service 01/10/06 users (contract and complaints procedure) should be amended to reflect that the Commission for Social Care Inspection is the regulatory body. Care plans are to be in place for 01/10/06 all people receiving a service from the home, whether permanently resident or occasionally. Dates and signatures are to be added to documents. Individual risk assessments are 01/12/06 to be in place and developed for all service users, which adequately reflect risk and actions to be taken to minimise risk. Health care policies and 01/02/07 procedures are to be reviewed and revised where necessary to reflect best practice and thereafter reviewed annually. Medication administration 15/09/06 records are to be in place for all DS0000023068.V289406.R01.S.doc Version 5.1 Page 26 Requirement 3 OP7 15 4 OP7 13(4) 5 OP8 10(1) 6 OP10 13(2) 7 OP10 13(2) 8 9 OP13 OP18 13(4) 13(6) 10 11 12 OP18 OP19 OP33 13(6) 16(2)c 24 service users whose medicines are handled by staff. A protocol on the use and circumstances for using “as required” lorazepam is to be written. A risk assessment is to be prepared on the public using the swimming pool. The Protection of Vulnerable Adults policy is to be revised and in line with the local authority procedures and state that notification is to be made to the Commission within 24 hours of any allegation, suspicion or actual occurrence of abuse. Update or first time training on adult protection is to be undertaken by all staff. Cantilever tables without the edging strip are to be replaced. An annual internal audit of the quality of the homes care and administrative procedures should be undertaken. Previous timescale of 31/03/06 not met. 15/09/06 01/10/06 15/10/06 01/09/07 01/11/06 01/01/07 13 OP38 13 A Legionella assessment of the 01/11/06 water supplies must be undertaken. Previous timescale of 31/03/06 not met. Risk assessments are to be 15/10/06 written on the use of supplementary electric heaters. Fire drills are to be take place at 01/09/06 least every six months and be recorded to show who was present, time of the drill (alternating with occasional night time practices), time to evacuate and any problems arsing. 14 15 OP38 OP38 13(4) 23(4) DS0000023068.V289406.R01.S.doc Version 5.1 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Good Practice Recommendations Standard OP30 Team meetings are to be minuted. DS0000023068.V289406.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000023068.V289406.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!